RIGHTS and RESPONSIBILITIES
The Medical Assistance Program will use my personal information (Name, Address,
Social Security Number, Date of Birth, Employment History, etc.) to see if I am eligible
for benefits. If I do not provide the information, my application may be denied. I have
the right to review, change, or correct any information. By law, the state may use my
information only for purposes directly related to the administration of the programs for
which I apply.
ASSIGNMENT OF RIGHTS OF PAYMENT FOR MEDICAL SUPPORT AND OTHER
As a condition of my eligibility, I assign to the state any rights to medical support and to
payment for medical care from any third party. I agree to cooperate with the state in
identifying and providing information to assist the state in pursuing any third party that
may be liable to pay for my medical care and services. I understand that I must report
to the local department of social services any payments received for medical care
within 10 days.
I understand that I must tell the local department of social services about any changes
in my income, assets (savings and checking accounts etc.), address, or living
arrangements within 10 days after the change happens.
APPLICANT’S STATEMENT OF UNDERSTANDING AND AGREEMENT:
I agree to the release of my personal and financial information to any agent of the state
who will evaluate and determine my eligibility for Medical Assistance benefits.
I understand that the state may verify all information on this form. Social Security
Numbers will be used for identification to verify information for program reviews or
audits and computer matches with other agencies, such as the Social Security
Administration or the Internal Revenue Service.
I have the right to appeal any decision, action, or inaction made concerning my
eligibility. I understand that my application will be considered without regard to race,
color, sex, age, disability, religion, national origin, or
I certify that everyone requesting benefits on this application form is a U.S. citizen or
lawfully admitted alien. Proof of lawful immigration status is required.
Keep this page for your records
DHR/FIA 9705 (Revised 01/10)